Specifications include, but are not limited to: 1. The administrator will be responsible for verifying coverage from the initial enrollment data of each plan year and any subsequent changes which are transmitted to it by PHSD. Claims can only be paid to participants in the plan. 2. The administrator must process all claims on a direct claim basis with no verification of claims by PHSD. 3. The administrator must process and make all necessary payments on valid and documented claims within five (5) working days from the receipt of the properly completed claim form. The administrator must issue payments each business day. In those cases where a claim cannot be processed due to lack of information or some other reason beyond the control of the administrator, notice must be sent within five (5) days from receipt of the claim, advising the employee of the nature of the issue preventing the claim from being processed. The notice must be clear, concise, and easily understood by the employee. 4. The administrator must review each claim and determine the appropriate benefit payment based on the terms and conditions of PHSD Flexible Benefits Plan in a manner which will ensure compliance with all applicable state and federal regulations. 5. The administrator must be able to recognize actual accrual of employee contributions in the determination of reimbursement amounts. 6. A listing of checks, debit card transactions or direct bank deposits to participating bank accounts, issued to pay claims must be made available to PHSD no less frequently than monthly. 7. The administrator must provide, with each payment, an explanation of the benefit paid. Explanations of Benefits must clearly identify the details of each submitted claim included in any payment...
